| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,279 |
3,278 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,952 |
1,451 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,690 |
2,690 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,059 |
3,059 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
3,027 |
3,011 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,650 |
1,650 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,880 |
2,877 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
276 |
229 |
$11K |
| D0274 |
Bitewings - four radiographic images |
671 |
671 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
364 |
364 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
165 |
133 |
$7K |
| D1351 |
Sealant - per tooth |
239 |
75 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
70 |
62 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
256 |
252 |
$5K |
| D1206 |
Topical application of fluoride varnish |
92 |
92 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
13 |
13 |
$650.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$250.68 |
| D0270 |
|
38 |
37 |
$175.00 |